West High Big Brothers Big Sisters

  Link to online form

OR

You can print the form below and return to school

Site-Based: Parent/Youth  Enrollment Form

Big Brothers Big Sisters of Dane County does not discriminate on the basis of race, religion, national origin, gender, marital status, sexual orientation, gender identity, veteran status, or disability.

Parent/Guardian Information

Full Name:			Relationship to Child:
	First	Last

Do you have legal custody of the child?  

Is there a person who shares legal custody of this child?      

If yes, are they aware and supportive of the child’s enrollment in the BBBS program?  ☐ Yes     ☐ No

Full Name:

Phone #:

Address:
	Street Address	Apartment/Unit #

	City	State	ZIP Code

Phone:

Email

Cell provider:

Best Time to Call: ☐ Anytime   ☐ Daytime   ☐ Evening   ☐ Weekend  

Are you currently employed outside the home?   

  

Parent Place of Employment:

Work  Phone:

May we contact you (the parent/guardian) at the work number listed?      

Is there a person who shares legal custody of the child? If so, what is their full name?     

May we contact you (the parent/guardian) at the work number listed?      

Child/Little Information

Full Name:				Date of Birth:
	First	Middle	Last

Gender:   ☐ Male   ☐ Female  ☐ Trans Male ☐ Trans Female ☐ Genderqueer/Nonbinary ☐ Prefer not to say

Preferred Pronouns:

Preferred Name:

Child Cell Phone:

Childd Emaill:

Child’s School:

Grade:

Race/Ethnicity  (check all that apply)		☐American Indian or Alaska Native    ☐Asian Indian   ☐Japanese    ☐Korean    ☐Vietnamese     ☐Other Asian    ☐Filipino    ☐Chamorro     ☐Samoan    ☐Native Hawaiian     ☐Other Pacific Islander    ☐Hispanic – Cuban    ☐Hispanic – Mexican, Mexican American, Chicano    ☐Hispanic – Puerto Rican    ☐Hispanic – Other Latinx or Spanish origin    ☐Black or African American    ☐Middle Eastern or North African    ☐White or Caucasian    ☐Prefer not to say     ☐Some other race or origin – please list:
Nationality:

Child’s Living Situation:

☐ Two-parent household     ☐ One-parent household (☐Female / ☐Male)    ☐ Other relative of child (non-parent)    ☐ Foster Home     ☐ Group Home     ☐ Other:

Does your child experience any of the following Dietary Modifications : Chronic Illness: Physical Limits: Behavioral Concerns: Developmental Delays:

Emergency Contact Name:			Phone:
Relation to child: